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Richard W. Riley College of Education
Winthrop University
106 Withers Building
Rock Hill, SC 29733
REQUEST FOR LEAVE
DURATION OF LEAVE:
p.m. Month / Day / Year
From: _______
a.m. ____ /____ /____
p.m.
Through: ______
a.m. ____ /___ /____
NAME
SOCIAL SECURITY NUMBER
Hours: ________ Minutes: __________
DEPARTMENT
Type of Leave Requested (Check one):
Other:
Annual Leave
Jury Duty
Sick Leave with pay — employee
Funeral Leave
Relationship: ______________________
Sick Leave with pay — family
Personal Leave without pay
Sick Leave without pay
Signature
Date
Approval
Date
***Please submit to Department Chair/Director
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